Banner - Hide this banner





Author Topic: PLC/LCL repair when varus deformity (bowlegged) present  (Read 10140 times)

0 Members and 1 Guest are viewing this topic.

Offline Mookie11

  • Forum Faithful
  • ****
  • Posts: 329
  • Liked: 0
  • Ouch!
PLC/LCL repair when varus deformity (bowlegged) present
« on: August 13, 2008, 12:21:00 AM »
So here is the scoop. Had major 6+ hour surgery on June 6th for PLC/PCL/LCL. OS told me while I was in hospital that he'd not noticed I was fairly bowlegged (varus deformity) until he'd already gotten into the procedures. He mentioned that the outcome of this big surgery may be in doubt as a result. I hadn't given it a lot of thought until last night when I was experiencing some discomfort etc. and decided to have a look around the KG site, among others, for more information. I was a bit dismayed to see that this reconstruction isn't recommended for individuals, like myself, who have this varus deformity. It is apparently a preferred option to have the legs made straight first.  So, I am wondering if there is anyone else who knows about this issue or who has experienced something similar, someone who is also bowlegged.

A little confused now,
Candace
Who knew knees were so complicated!

Offline knee-will-be-great

  • Forum Faithful
  • ****
  • Posts: 390
  • Liked: 0
  • Open-wedge HTO & ACL allograft done (YES!)
    • ACL Allograft #3 Post-Surgery Rehab/Wellness Diary
Re: PLC/LCL repair when varus deformity (bowlegged) present
« Reply #1 on: August 13, 2008, 05:58:31 AM »
Hi there,

I would think that an OS could consider a high tibial osteotomy (HTO) to correct the varus deformity.  Of course, from my understanding it makes sense to correct the varus deforminty first and then do the ligament reconstruction - becausde if the OS is trying to reparie the ligaments and the PLC whilst the knee is varus, then conceiveably the liaments will be out of line after the HTO.

An HTO provides a person with a straightened knee relative to what they had previously.  A varus knee can be as a result of wear and tear of the knee joint this allowing the knee joint to collapse in - or as a result of surgical removal of cartilage on the medial side of the knee - or it can be congenital (you are born that way).

I had a HTO because of lack of cartiilage on the medial aspect of my knee - owing to previous meniscal removal.  My knee had collapsed and I was bow-legged on that leg.  I then had an ACL allograft the following year to stabilise the knee.  My OS would not have done the ACL frstly - because the leg would have been in varus position.

Hope this helps somewhat.

Knee - will - be - great.
Medial Menisectomy, 1 ACL Autograft, 3 ACL Allografts, HTO, numerous debridements, good now :)
ACL Allograft #3 Post-Surgery Rehab/Wellness Diary http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=37218.0;all
ACL Reconstruction VIDEOS http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=37773.0

Offline ATsoccergirl

  • SuperKNEEgeek
  • *****
  • Posts: 1394
  • Liked: 1
  • Practice safe sports, use an athletic trainer
Re: PLC/LCL repair when varus deformity (bowlegged) present
« Reply #2 on: August 13, 2008, 05:01:15 PM »
The surgeon who reconstructed my PLC developed many of the surgical techniques for this procedure.  He is extremely careful about knee alignment.  I had to undergo multiple X-rays, a CT, and various measurements to determine my knee alignment before surgery could even be scheduled.  My alignment is neutral to a slight valgus alignment.  He was also able to tell just by looking at my knees what my alignment was. 

I would be more than confused in your case, I would be mad.  Your surgeon performed a risky (due to the amount of time under anesthesia) procedure which is doomed to fail.  The other thing with PLC reconstructions, is you really only have one chance to do it right.  If a revision is necessary generally the results are far from ideal and it's really more of a salvage procedure than anything.  If you where to undergo a HTO now, as was said before the ligaments would be out of wack with your new knee alignment, which would require revision of the ligaments. 

It is unimaginable to me that your surgeon would fail to notice that you have a varus deformity until during surgery.  When I was going through school (athletic training) observation is one of the first skills that you learn, and knee alignment is one of the first things that you look at when evaluating a knee injury.  To me, his actions are negligent.  I assume that you had some imaging studies done prior to surgery, x-rays, MRI, etc.  I would go back and get the radiologist's report from them to see if there is any mention of alignment.  Typically it is something that is noted.  If it is mentioned by a radiologist, you may want to consider legal action against your surgeon for his gross oversight. 
1999 LR, 2002 ACL/PLC recon, reversal of LR, 2004 ACL revision, 2006 Car accident torn PCL and small fractures resulting in bone chips in my knee.  Torn MCL 3 times.  Wicked screws under IT band and Pes Anserine.  June 2008-Hip Arthroscopy.

Offline Mookie11

  • Forum Faithful
  • ****
  • Posts: 329
  • Liked: 0
  • Ouch!
Re: PLC/LCL repair when varus deformity (bowlegged) present
« Reply #3 on: August 13, 2008, 09:24:31 PM »
Thanks for your reply. I am not grossly bowlegged but neither did I have a long legged standing X-Ray as is suggested on the KneeGuru site. The only tests I had were a simple knee X Ray looking for breaks when I was originally hurt over a year ago and an MRI a few months prior to the reconstruction.  I will have to ask my OS if perhaps the bowleggedness I experiece is perhaps considered minimal and therefore went unnoticed until he was trying to achieve satisfactory alignment and fixation. I knew I was bowlegged though.... when I was a kid I was seen by a surgeon who opted to take a wait and see approach as he felt that as I grew the issue might resolve itself. After that it was kind of dropped and never really posed a problem other than a bit of teasing. Had I done my research prior to having this procedure, I would have mentioned it to the OS. I kind of feel the onus is on me too. I should have been aware and asked the appropriate questions. I am reserving the option of thinking poorly of the OS until I've had a chance to see him again at the end of September and seek some answers. Perhaps there was reason behind his decision to proceed.  Other than this bit of paranoia that I am experiencing after reading the KneeGuru information, I am thus far happy with the results. Time will tell.
Candace
Who knew knees were so complicated!

Offline sbwestin

  • MICROgeek (<20 posts)
  • *
  • Posts: 12
  • Liked: 1
  • User's Text
    • Cincinnati Sportsmedicine
Re: PLC/LCL repair when varus deformity (bowlegged) present
« Reply #4 on: August 23, 2008, 09:20:56 PM »
Candace,

When you are able to bear all of your weight, you should insist on having full standing x-rays (hips to ankles) and be provided with both the weight bearing line (WBL) and mechanical axis of both limbs. There are standard measurements that experienced surgeons use to determine if a high tibial osteotomy is warranted. A WBL of 50% indicates that the forces of weight upon walking are evenly distributed between the medial and lateral compartments of the knee. A WBL less than 50% indicates varus alignment (forces are focused more on the medial compartment), whereas a WBL greater than 50% indicates valgus alignment (forces are focused more on the lateral compartment).

Keep in mind that the x-ray represents a static measurement - what is really required is a formal gait analysis that determines, during walking, exactly how the forces are distributed throughout the hip, knee, and ankle joints. However, there aren't many gait laboratories and I' not sure where you are located.

How was your PL deficiency corrected? Through one or two grafts? Or with an advancement procedure or biceps tendon transfer? Same with the PCL - how was this surgically reconstructed? We published have studies that assessed the causes of failure of both PCL and PL reconstructions and, just as in failed ACL reconstructions, failure to correct varus malalignment was a common cause. I am happy to e-mail you these publications if you are interested. This is why it is important to determine exactly how much of a varus deformity exists in your lower limb.

Good luck with your recovery,

SueBW


Lateral release x 2
Bilateral arthroscopic subacromial decompression, distal clavicle resection
Repair tennis elbow
Partial lm, chondroplasty MFC, femoral sulcus

Offline Mookie11

  • Forum Faithful
  • ****
  • Posts: 329
  • Liked: 0
  • Ouch!
Re: PLC/LCL repair when varus deformity (bowlegged) present
« Reply #5 on: August 25, 2008, 10:01:35 AM »
Hi Sue,
Thanks for the informative reply!

I had a PCL autograft from the petallar tendon. One of the holes in the bone plug cracked making the the graft partially fragmented, but it was used anyways as it was still held together by the tendon. Notchplasty was required. Somehow the tibial tunnel became overly enlarged during the process of passing the patellar autograft so the the guidewire for the tibial interference screw was passed anterior the bone graft to try and keep it in as decent a position as possible. There was an 8mm biosorbable interference screw attaching the femoral end and a 10mm screw as well as #5 Ethibond and another 4mm screw and washer on the tibial end.

There was some kind of tidy up for the ACL, but a graft was not required

Laterally, it was found that remnants of the iliotibial band, the fibular collateral ligament, the popliteus, lateral collateral ligament, and capsule had all healed in a giant tangled mess of scar tissue. It had been hoped that an advancement could be performed to stabilize the posterolateral corner, but there was not sufficient  structural integrity so reconstruction with semitendinosis was completed instead. I do not know if this reconstruction was using one or two grafts as there were pieces taken from Sartorius, and though I have the 3 page surgical report in front of me I don't quite understand it. I do suspect it is a single graft looped. I know that there were several drill holes into the lateral femor, the anterior to posterior portion of the fibula head, etc. Once the process was completed, it had to be redone as acceptable isometricity and fixature were not achieved. I know  in at least one instance a second set of drill holes had to be made proximal to the first. In the end there was 2 cm of Wire, a 6mm biotinidases, a 23 mm biotinidases and an 8 mm screw and washer used in this portion of the reconstructions.

Finally, the surgical report indicates that the remnants of the capsule and the "other" damaged structures were sewn down over top of the recunstruction followed by repair to the iliotibial band.

It was not until I was seen by the surgeon later in the hospital room that he commented he'd had a difficult time getting proper isometricity as I was bowlegged, which he had not realised I was prior to surgery. I can't say how much of a varus deformity exists, though I have always known I was bowlegged. Had I come across the KneeGuru site prior to surgery, I would certainly have mentioned this issue to the surgeon. I can't account for why I had none of the full standing x-rays prior to surgery. It is a mystery.

I would be very interested in reading any articles you might be able to email me at [email protected]

Thanks so much, SueBW!
Who knew knees were so complicated!

Offline Mookie11

  • Forum Faithful
  • ****
  • Posts: 329
  • Liked: 0
  • Ouch!
Re: PLC/LCL repair when varus deformity (bowlegged) present
« Reply #6 on: October 09, 2008, 07:18:46 AM »
A quick informational update.

I saw the surgeon this week and expressed some of my concerns re an incident at physio and my suspicion that I'd lost or stretched the LCL and who knows what else. It is the opinion of the surgeon that I have indeed suffered a failure to the LCL. The original instability has returned. While I was in his office, he had me stand in front of him so he could look at my legs side by side from a standing position - first time he's done this. He commented that I had "the cowgirl thing" going on. He says it is possible I may be able to strengthen the muscles around the knee so as to avoid what comes next but that it isn't likely. It sounds as that I will have to have the leg straightening procedure and then a salvage of the rest.

Word to the wise. If you suspect you are bowlegged and your OS hasn't checked for that, bring it to his attention!!!!!!!!!!!!!!! I can't stress that enough.

All the best,
Candace
« Last Edit: October 09, 2008, 07:24:22 AM by Mookie11 »
Who knew knees were so complicated!

Offline Mookie11

  • Forum Faithful
  • ****
  • Posts: 329
  • Liked: 0
  • Ouch!
Re: PLC/LCL repair when varus deformity (bowlegged) present
« Reply #7 on: November 07, 2009, 09:11:25 AM »
Thought I would chime in with an update. One year later and it has become clear, after an appointment to an out of town, big city univeristy sports medicine surgeon, that I require an HTO.  He did the required long legged X-rays and determined that the medial side of the knee is compressing while the lateral side is opening up due to the varus deformity. I was required to purchase a customer made Ossure Lite Unloader Brace and it has made a world of difference. While the brace is on, the instability issues are mostly resolved. With the brace on I can actually jog a little for the first time in 2 1/2 years, something I never thought I would be able to do again, not even 2 paces. The results of wearing the brace were immediately noticeable. The surgeon has indicated that should I notice a difference while wearing the brace, it would signify that an HTO would indeed be indicated. As such, I have submitted to having the operation at some point in the New Year. Without the brace I continue to limp and to have issues. With the brace I can actually run a bit.  Quite an amazing difference.

All the best to those of you who may be experiencing on going knee issues.

Candace
Who knew knees were so complicated!